What do the public, patients and health professionals think about the design of an intervention trial to reduce anticholinergic burden?

Problem

Medications with anticholinergic properties are prescribed in 20-30% of older people despite their known association with negative health-related outcomes. The risk varies greatly between medications, and accumulates with polypharmacy to create an anticholinergic burden (ACB). NICE highlights that increased ACB is associated with cognitive impairment and should be reduced in those with dementia. Here we explore stakeholder (patients/public/health professionals) perspectives of barriers and facilitators to reducing ACB. The work reported here is preparatory research for a proposed ACB deprescribing trial which aims to reduce ACB in an at-risk population (older people with multimorbidity and polypharmacy) in a primary care setting.

Approach

We undertook three focus groups and ten individual semi-structured qualitative interviews with 22 older adults with polypharmacy, as well as two focus groups and seven semi-structured qualitative interviews with a range of health care professionals (HCPs) including GPs, geriatricians, and pharmacists (n=16).We explored views about barriers and facilitators to ACB reduction and the design of any future ACB reduction trial.All focus groups and qualitative interviews were digitally recorded and transcribed verbatim and the transcripts served as the data for qualitative analysis. Data analysis was underpinned by Normalization Process Theory (NPT). NPT explains how the work of enacting an ensemble of tasks or practices is accomplished through the operation of four mechanisms: ‘coherence’ (sense-making work); ‘cognitive participation’ (relationship work); ‘collective action’ (enacting work); and ‘reflexive monitoring’ (appraisal work).

Findings

Key “take home” messages for any future ACB reduction trial in the community were: (1) The public, patients and health professionals were generally positive about the possibility of running a trial of deprescribing (sense-making work); (2) Ensure patient engagement from the outset to enable concerns and potential pitfalls to be addressed (relationship work); (3) Clear communication is essential so that patients involved in any trial have a very clear understanding of the rationale and to minimise the potential for misconceptions about the reasons for ACB reduction (relationship work); (4) It would be important to provide access to a point of contact for patients throughout the life of a trial to address queries or concerns (enacting work); (5) Minimise the workload implications of any trial and use IT systems, if this would make the enacting work of practitioners easier (enacting work); (6) Pharmacists are best placed to carry out ACB reviews, though overall responsibility for patient medication should remain with the GP (appraisal work).

Consequences

These findings, together with other preliminary work carried out by the team provide key insights which will be crucial in planning and developing a large-scale RCT of deprescribing or medication switching that aims to reduce ACB in the older general population.